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Diseases of the Ear Nose and Throat (ENT)

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Diseases of the Ear Nose and Throat (ENT) STANDARD TREATMENT GUIDELINES Diseases of the Ear Nose and Throat (ENT) DEPARTMENT OF HEALTH AND FAMILY WELFARE GOVERNMENT OF KERALA STANDARD TREATMENT GUIDELINES IN ENT Four sections Section I Common diseases of EAR Section II Common diseases of Nose Section III Common diseases of Throat Section IV ENT emergencies Committee for development of Standard Treatment guidelines ENT CONVENOR Dr. Suchit Roy B R Professor & HOD of ENT, Government Medical College, Thrissur MEMBERS Dr. Satheesh S, Professor & HOD of ENT, GMC, Thiruvananthapuram Dr. Sunil Kumar K P, Professor of ENT, GMC, Kozhikode Dr. Venugopal M, Professor, GMC, Thiruvananthapuram Dr. Shibu George, Professor & HOD of ENT, GMC, Kottayam Dr. Sadarudheen Ahmed, Professor & HOD, GMC Eranakulam Dr. Herman Guild M John, Professor & HOD, GMC Alappuzha Dr. Thulaseedharan S, Additional Professor & HOD, GMC, Kollam Dr. Suma Radhakrishnan, Additional Professor of ENT, GMC, Manjeri, Dr. Binu Raju George, Associate Professor, GMC, Thrissur Dr. Susan James, Associate Professor of ENT, GMC,Thiruvananthapuram Dr. Sindhu V Nath, Associate Professor of ENT, GMC, Thiruvananthapuram Dr. Salima Rema Windsor, Associate Professor of ENT, GMC, Kollam Dr. Divya G M, Assistant Professor of ENT, GMC, Kozhikode Dr. Salil Kumar K, Principal, SUT MC, Thiruvananthapuram Dr. Paul Samuel, Sr Consultant, Cosmopolitan Hospital, Thiruvananthapuram & Secretary, AOI, Thiruvananthapuram Chapter, Kerala State EXTERNAL EXPERT Dr. Rupa Vedantam, Professor & HOD, CMC Vellore “Driven by the inspiration drawn from Shri. Rajeev Sadanandan IAS, Additional Chief Secretary, Department of Health and Family Welfare, Government of Kerala, the process of preparation of Standard Treatment Guidelines (STG) was initiated by the Director of Medical Education Dr. Remla Beevi A. The process of developing and finalizing the STG’s were coordinated by Dr. Sreekumari K. Joint Director Medical education and Dr. Suma T K, Professor of Medicine and ably supported by a dedicated team of experts, including external faculty”. TABLE OF CONTENTS Message from CM 9 Message from HM 11 Foreword ACS 13 1. Common diseases of ear 15 1.1 Definition 17 1.2 Acute otitis externa 17 1.3 Malignant external otitis 20 1.4 Acute otitis media in children 24 1.5 Otitis media with effusion 29 1.6 Chronic otitis media 34 1.7 Permanent childhood hearing loss 38 1.8 Idiopathic sudden SNHL 42 1.9 Bell's palsy 45 1.10 Ménière's disease 49 1.11 Benign paroxysmal positional vertigo 51 2. Common diseases of nose 55 2.1 Rhinosinusitis 57 2.1.1 Introduction 57 2.1.2 Acute rhinosinusitis 57 2.1.3 Chronic rhinosinusitis in adults 59 2.1.4 Chronic rhinosinusitis in children 61 2.1.5 Fungal sinusitis 61 2.1.6 Fungal Rhinosinusitis 61 2.2 Epistaxis 68 2.3 Allergic rhinitis 74 3. Common diseases of throat 81 3.1 Cut throat 83 3.2 Dysphagia 91 3.3 Dysphonia 97 3.4 Foreign body throat 101 3.5 Deep neck space infections 104 3.6 Stridor 112 4. ENT emergencies 117 4.1 Facial trauma 119 4.2 Ear trauma 121 4.3 Facial paralysis 123 4.4 Ear ache 125 4.5 Foreign body ear 127 4.6 Foreign body nose 129 4.7 Headache 131 4.8 Vertigo 134 Message Pinarayi Vijayan Secretariat Chief Minister Thiruvananthapuram The Government is taking many initiatives to ensure providing quality health care to all. Out of the five missions launched by the Government, the Aardram mission is primarily focussed to improve Primary Health Care to provide standard health care facilities to people at grassroots. This initiative is complemented by strategic investment for the improvement of infrastructure in secondary and tertiary health care institutions to provide quality health care services. I am happy to note that the Department of Health is also taking initiatives to bring standardization in treatment for various disciplines like Cardiology, Critical care, Diabetes Mellitus, Cancer Care, etc. It is a noteworthy initiative to improve the qualitative aspects of the health service delivery. I appreciate the efforts taken by the experts from Government sector and private sector from Kerala and also the subject experts from outside the state. I am hopeful that the introduction of standard guidelines for diagnosis and treatment will ensure better quality and consistency in health care. I wish all the success to this endeavour. Pinarayi Vijayan Chief Minister 9 Message 11 Foreword Patient care has moved away from management by an individual based on personal knowledge and skill to an evidence based, team managed operation. Decisions are reviewed more rigorously post facto and their alignment verified with standard practice. With the mode of payment for care moving from out of pocket payments to third party payers there will be a demand for rigorous documentation and evidence of having conformed to standard practice. When analysis of big data and machine learning becomes the norm it will require a standard set of procedures to act as the baseline from which to measure deviations and differences in impact. To meet the requirement of these developments in the field of medicine, it is necessary to have explicit, objectively verifiable set of standard operating procedures. They have to be prepared based on international guidelines with the highest acceptance, but have to be modified to suit local knowledge and practice, so that there is local ownership. Government of Kerala has been trying to get the guidelines prepared for some time now. I would like to thank and congratulate Dr. Sreekumari, Joint Director of Medical Education and Dr. T.K.Suma, Professor of Medicine, T.D. Medical College, Alappuzha who took on the task of preparing standard treatment guidelines and completed it through a long, consultative process. I also thank the conveners of the different thematic groups who coordinated the work in their field as well as the innumerable number of participants, in government and private sector, who contributed their effort and knowledge to improve the guidelines. Professional associations have also contributed in their fields. Their efforts have resulted in a product they and Kerala can be proud of. Treatment guidelines cannot be static if they are to remain relevant. They must be updated based on new knowledge and the 13 experience of treatment based on these guidelines. To do this the group which prepared the guidelines has to remain active and have a system for collecting data on the results of practice based on these guidelines. I hope such an activity is institutionalised and periodic revisions of the guidelines are prepared and published. I wish that these guidelines contribute to raising the quality of patient care in Kerala. Rajeev Sadanandan IAS Addl Chief Secretary Health & Family Welfare Department 14 Section I Common diseases of EAR STANDARD TREATMENT GUIDELINES ON COMMON EAR DISEASES Section I Section I 1. COMMON DISEASES OF THE EAR SCOPE The purpose of this guidelines is to identify quality improvement opportunities in managing common diseases of the ear and to create explicit recommendations to implement these opportunities in clinical practice. Specifically, it is intended to educate all specialists involved in the evidence-based management of ear diseases with set goals to improve diagnostic accuracy, identify sequelae or complications early, advice rational investigations and prescribe only scientific treatment. This guideline is applicable in any setting where patients with ear disease would be identified, monitored, or managed. This guidelines, however, does not apply to management of ear diseases at the primary care set up. 1.1 DEFINITION The management guidelines of common ear diseases comprises of guidelines for diagnosis of ear diseases based on symptoms and signs, essential investigations to confirm the diagnosis and rational treatment options, both medical and surgical. PURPOSE OF RECORD To ensure uniform, scientific and ethical management of common ear disease 1.2 ACUTE OTITIS EXTERNA INTRODUCTION Defined as diffuse or localized inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. Usually represents acute bacterial infection of the external canal (most commonly Pseudomonas aeruginosa & Staphylococcus aureus), but may also be caused by fungal infection, viruses or skin diseases. Key points in diagnosis ü Rapid onset; usually within 48 hours. ü H/O preceding trauma (e.g.; forceful ear cleaning, use of ear buds) OR exposure to water (e.g.: swimming) ü Symptoms: Earache (often severe) &/or jaw pain, itching, hearing loss or fullness, discharge. (Pain aggravated by jaw movements). ü Signs: Tenderness of the tragus, pinna, or both. ü Diffuse oedema of ear canal oedema, erythema, or both. 17 Section I STANDARD TREATMENT GUIDELINES ON COMMON EAR DISEASES ü Serous or purulent otorrhea, Pre / post aural lymphadenitis, Congested tympanic membrane. ü Sometimes presents as localized inflammation of hair follicle of cartilaginous canal (furunculosis); can lead to abscess formation. ü If otomycosis- thick greyish discharge with black (Aspergillus Niger) or white (Candida albicans) fungal colonies visualized on otoscopy (resemble wet news-paper when taken out). ü Routinely no investigations necessary. ü Culture & Sensitivity of the discharge recommended if immunocompromised; in adults with recurrent external otitis investigate to rule out latent Diabetes mellitus. MANAGEMENT GUIDELINES 1. Analgesics recommended based on the severity of pain. 2. Systemic antibiotics not recommended routinely for primary treatment, or uncomplicated external otitis. However, to
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